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Microsoft powerpoint - eggthaw_orientation_060513 [compatibility mode]


Egg Thaw Cycle Orientation Visit us online at www.NYUFertilityCenter.org  Copyright 2008 – 2013 NYU Fertility Center – rev. 06/05/2013








Meet Our Physicians Dr. Frederick Licciardi
Dr. James Grifo
Dr. Nicole Noyes
Dr. Alan Berkeley
Dr. Lisa Kump-Checchio
Dr. M. Elizabeth Fino
Dr. David Keefe
Reproductive Endocrinology Fellows The NYU Fertility Center is part of the Division of Reproductive Endocrinology and Infertility (REI) at NYU School of Medicine's Department of Obstetrics and Gynecology.
Our division offers a 3-year fellowship program in Reproductive En Obstetrics and Gynecology. Fellows are licensed physicians and have completed 4-year residencies in Ob-Gyn and have elected to sub-specialize in REI.
Throughout your time at the NYUFC, you will interact with our fellows who provide clinical care and provide on-call responsibilities (including emergencies).
Reproductive Endocrinology Fellows  Brooke Hodes-Wertz, MD  Jason Kofinas, MD Satellite Programs Madison Women's Health & Fertility, P.C.
(select physicians only)
50 East 77th Street, New York, NY 10021 Phone: (212) 639-9122
 Maureen O. Moomjy, MD  Jessica R. Brown, MD Greenwich Fertility and IVF Center, P.C.
55 Holly Hill Lane, Suite 270, Greenwich, CT 06830 Phone: (203) 863-2990  Barry R. Witt, MD  M. Elizabeth Fino, MD Laboratory Schedule  The NYU Fertility Center's Embryology Laboratory closes three times a year to perform maintenance. Closures occur in:  NYUFC continues to provide monitoring, consultations and non-egg/embryo thaw procedures during the closure period.  When scheduling your thaw cycle, please make sure you can meet the cut-off dates before each shut down. Contact the Patient Coordinators with any questions you have regarding the cut-off dates.
Patient Care Staff  Patient Coordinators  Peggy Chin (212) 263-3385  Maribel Feliciano (212) 263-7967  Kamini Persaud (212) 263-7647  Jackie Hernandez (212) 263-0375  Diane Gandolfi (212) 263-2728  Shantel Morrison (212) 263-8652  Nancy Kerns-Amsel (212) 263-0036 Male Services ( S/A Appts)  Medical Assistants  Lavina Mui (212) 263-7931  Imelda Weil (212) 263-7976  Billing Associates Group  Lindeena Harris (212) 263-0026  Frequency of monitoring is based on your individual results of  Blood Test and Ultrasound Hours: 7:00AM to 9:00AM, 7 days per week,
no appointment necessary
Please try to avoid the 8:59AM rush, particularly on weekends.
 We will call with medication instructions the afternoon of your visit. Be prepared and have all medications you will need early in the day and before weekends.  Follow instructions exactly. Call with questions: 212-263-8990  Best time to call nurses: after 9:30AM until 5:00PM  If your orientation nurse is out of the office, other IVF nurses can assist you.
The Female Reproductive System Location of Organs
Fallopian Tube and Ovary
Illustration Courtesy of Organon Prerequisite Tests, Consents & Appointments  Required consultations and tests must be completed before your thaw cycle
 Please inform us if you or your partner have any medical condition or allergies, or are on any prescription medications or herbal supplements. Some medical conditions will require documented clearance from your personal physician or specialist.  Your "Advance Directive" ( if you have one) should be provided at the start of treatment. Information available from your MD's assistant.
 All consents for procedures and releases from cryopreservation must be completed, properly signed and witnessed prior to starting any medication.
 Incomplete testing or consents will delay the start of your cycle.  No consent or lack of required testing means "No Start".
Morning Monitoring Hotline  Please call us at (212) 263-8999 on the day or evening  Day 2 or Day 3 start date for Egg Thaw or FET  Record your name-spell it out, physician and your protocol. Notification will allow your chart to be available before you arrive.
 At today's orientation
 Your medication protocol and your egg thaw schedule will be reviewed.
 If you are considering whether or not to move forward, please call one of our patient coordinators, Jackie Hernandez or Maribel Feliciano at least one month prior to when you want to start to reserve a place on our start calendar. There are times when we are fully booked or in downtime and your treatment cycle may be delayed.
 *** If you have any insurance, be sure to consult with our billers regarding your the billing group.
 For Egg Thaw
 Visit us on cycle day 2 between 7:00AM to 9:00AM for an estradiol blood test and a
baseline sonogram.  If you need your prescriptions, obtain them from the nurse on Day 2 while at morning monitoring. If you do not require prescription authorization the prescriptions can be called in to your pharmacy. Please have the pharmacy information available.  Pre-certification for your medication in addition to your procedure may be required by your insurer. We will assist you with the process, but all information must be provided based on your individual insurance requirement. Every cycle, even repeats must be authorized in advance. Shalanda Davis (212) 263-6498 or Jennifer Bush (212) 263-0392 (Monday-Friday only). Please provide us with all forms required by your pharmacy plan.  Your pharmacy benefit plan will determine the type ofand quantity of medication that can be dispensed for your cycle at any one time.
 Patients must be aware of the pharmacy benefit and its limitations - we can assist you, but we are unable to circumvent the plan's requirements. Egg Thaw Medication  Your physician has determined your medication protocol. If you have questions or concerns, please
address them BEFORE you start the cycle.
 The decision to start a patient's medication is usually based on your Day 2/Day 3 blood test and approval of your insurance carrier. Medications, once dispensed, cannot be returned to the pharmacy for credit, so wait for your instructions before filling your medications. Egg Thaw Medications  Estradiol -Estrace™  Doxycycline (antibiotic)  An antibiotic is prescribed for the male partner Proper Needle Disposal is the Law  Please collect your needles and syringes  Use a red "sharps container" (available at your pharmacy)  Use a clean soda bottle with a cap or similar container  Bring the closed container to us and we will legally
dispose of them with our licensed medical waste company  Your local hospital may accept the used items for disposal  You can call your local health department for a legal drop-off facility  Do not mail your syringes and or needles to NYUFC for disposal
Antibiotics for Male Partner  Purpose: Protects against infection of the embryos.
 Type: Doxycycline
Ciproflox will be prescribed for patients allergic to doxycycline. Please inform us if you have an allergy to "Cipro" or other medications.  Administration: oral medication, 100 mg twice a day (10 – 12
hours apart) for 10 days, beginning on the Day 5 of the female partner's stimulation cycle. Advise your nurse of any medication or food allergies.
 Possible Side Effects: photosensitivity, gastro-intestinal
Embryology and Andrology Embryology and Andrology Embryology and Andrology  The same day the eggs are thawed, the partner produces a fresh sample. Date and time determined by the embryology lab staff.  If you are using donor sperm, it will be thawed the same day as the eggs.
special medium for fertilization.
 The dish is placed in an incubator where normal fertilization occurs.  The resulting embryos are evaluated for 3 to 6 days; the best are placed into the uterus. The patient has the option to cryopreserve (freeze) excess, good-quality embryos; this requires a separate consent form.
Illustration Courtesy of Organon  To optimize fertilization, all Egg thaw cycles use Intracytoplasmic Sperm Injection (ICSI) – a lab procedure when a single sperm is injected into the egg Assisted Hatching  Assisted Hatching – this is very rarely used- an opening may be made in the "shell" surrounding the embryo to assist implantation when transfer is on Day 3 Embryo Development  The day after thaw, you will be contacted to receive preliminary results of fertilization. Please ensure the telephone number we have on file is correct. the number of embryos to be transferred. Because we may need to change the day of your transfer from Day 3 to Day 5, please ensure the staff can reach you by telephone.  Selected embryos are transferred directly into the uterus during a 10 to 15 minute procedure; sedation usually is not required.
Blastocyst Transfer on Day 5  Purpose:
To reduce the occurrence of multiple gestation without compromising the pregnancy rate.
The blastocyst stage represents the most advanced stage of embryo development in the laboratory. These embryos have the best chance of implanting. As a result, the transfer of fewer embryos will achieve a clinical pregnancy as often as more embryos transferred earlier in the cycle.
Criteria for Day 5 Transfer  Number of eggs at retrieval, fertilization rate and embryo development by day 3 post-retrieval determine day of transfer.
sufficient numbers of good quality embryos for Day 5 Transfer.
 The decision to transfer on Day 3 or Day 5 has to do with the ability to accurately select the best embryos for transfer.
Embryo Transfer Guidelines  The number of embryos to be transferred is determined by program guidelines and is influenced by factors including patient history, age and embryo quality. Recommended limits on the numbers of embryos to transfer
<35 yrs
35-37 yrs
38-40 yrs
41-42 yrs
a See text for more complete explanations. Justification for transferring one additional embryo more than the recommended limit should be clearly documented in the patient's medical record.
b Favorable = first cycle of IVF, good embryo quality, excess embryos available for cryopreservation, or previous successful IVF cycle.
Practice Committee Number of Embryos Transferred. Fertil Steril 2009.  It is very important to discuss these guidelines with your physician prior to the start of your IVF cycle. Some insurance carriers and states limit the number of embryos that may be transferred to maintain insurance coverage.  Single embryo transfers are also performed at the patient's request and sometimes at the program's recommendation. Some insurers encourage SET.  The decision regarding the number of embryos to replace in your Embryo transfer (ET) is an important one for you and, if applicable, your partner. The decision has significant implications for your health, the health of your achieve pregnancy.  Please review the information regarding clinical pregnancy outcomes and multiple gestation as impacted by the number of embryos replaced. This data is derived from IVF cycles conducted here at the NYU Fertility Center in 2009-2011.
Clinical Pregnancy Rate per Embryo Transfer Patient Age
Elective Single Embryo
Two Embryo Transfer
at Egg Retrieval
Transfer (SET) Day 5
 Purpose: supports the uterine lining to sustain embryo
implantation and pregnancy  Administration: injectable progesterone or a vaginal
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 Possible side effects: cramping, headache, nausea,
breast tenderness, mood swings or vaginal irritation.
 Please let your physician or nurse know if you have any nut
Post-Transfer Monitoring (Luteal Monitoring)  Progesterone blood test: day of transfer.
 Pregnancy blood test: mandatory at a date to be
determined by the Fertility Center. May be repeated 1 week later if positive, often sooner if level is "borderline" to identify th insurance may dictate the # of pg tests it will cover.  Pregnancy ultrasound: 1 to 2 weeks after the second
pregnancy blood test.
 Transfer to obstetrician of your choice: once detection of
fetal heartbeat is documented.
Frozen Embryo Transfer Cycle (FET)  An FET cycle can only be initiated after consultation with your physician and a reservation is in place. Insurance authorization may also be required. A reservation will not be provided unless authorization is verified.
 Patients undergoing FET must have a properly signed and witnessed consent before starting treatment. Patient cannot start a cycle without an
FE
 Visit us on day 2 of your menses between 7:00AM to 9:00AM for a blood
test and sonogram. Begin oral Estrace® as directed by your physician.
 Visit us on day 14 of your menses between 7:00AM to 9:00AM for a blood
test and a sonogram, and to schedule a transfer date. We will call you with the date and instructions regarding your transfer and start date of progesterone administration.
Consent Forms Required  Embryo Cryopreservation and Egg Thaw Consent.
 Donor Sperm (if needed) – An additional consent is required for the use of donor sperm.
 PGD/PGS (if needed) - Be sure you have received the PGD/PGS packet and have confirmed the PGD/PGS schedule with Reprogenetics or other PGD lab directly.
 NYU School of Medicine Institutional Review Board consents for research Consents must be completed in advance of the procedure. Not the day of thaw.
Program Consents

_ Initial Each Page _Sign and date the last page _ Initial Each Page _Sign and date the last page Please DO NOT use a checkmark for consent elements which
require a specific decision. Record your initials where
appropriate.
Research Consents
 A research consent CANNOT be witnessed by a Notary Public.
Signing Consents: Program Consents  All research at NYU Langone Medical Center must be approved by an ethics review board consisting of physicians, researchers and non-medical staff. This panel, called the Institutional Review Board (IRB), decides what research may be performed.
 IRB research consent permits use of discarded materials for  Only materials that would otherwise have been discarded will be used for research studies.
 Providing consent for research on discarded materials will not in any way jeopardize your medical treatment.
 Declining consent will not adversely affect your medical treatment.
Research Consent  Providing consent permits us to improve scientific techniques and to further understanding of infertility and its treatment.
 Without the consent of patients like yourselves, IVF or egg freezing would never have been developed.  Only through your consent can the techniques for fertility preservation or infertility treatments be developed further.
Research Consent  Examination of genetic abnormalities in embryos that have stopped dividing and are therefore not suitable for transfer or freezing.
 Analysis of follicular fluid to determine whether molecular signals in this fluid will predict which eggs and embryos are most likely to create viable pregnancies.
 Examination of signals from cells surrounding the developing oocyte to help predict which oocytes are likely to create pregnancy.
 Continuous monitoring of the discarded embryos for several days in a special incubator to gain more information about early embryo development.
 NYU Fertility Center is not involved in any activity that promotes human  For your individual situation, please contact your physician.
 2001- 2010, NYU Fertility Center performed 12,790 IVF cycles using fresh, non-donor eggs, resulting in 10,618 retrievals and 3,661 deliveries. Patient Age at
# of Oocyte
Deliveries
A comparison of clinic success rates may not be meaningful because patient medical characteristics, treatment approaches and entrance criteria for ART may vary from clinic to clinic. Issues to Consider Before Thawing Eggs  Multiple pregnancy  Elective reduction of multi-fetal pregnancy  Pre-term labor and cesarean delivery  Cryopreservation of additional embryos  The decision to cryopreserve is an important one that should be made prior to creating embryos  Custody in the event of death or divorce  Donation for research Issues to Consider Before Thawing Eggs  Multiple pregnancy (continued)  In 2010, the Program reported 239 deliveries resulting from fresh, non-donor egg cycles. Of these, 59 or 25% were multiple births – all twins, no triplets. This data does not include PGD cycles.
at Retrieval
A comparison of clinic success rates may not be meaningful because patient medical characteristics, treatment approaches and entrance criteria for ART may vary from clinic to clinic. Additional Services: PGD, PGS, Egg Freezing 45  Preimplantation Genetic Diagnosis (PGD)  Single Gene Defect, Aneuploidy, Translocations  Fees for NYU and for Reprogenetics or other PGD labs  Under certain circumstances may be covered by insurance carriers  Egg Freezing: Elective or Medical  No services affiliated with egg freezing are covered unless you have insurance coverage specifically for egg freezing Ectopic Pregnancy  Even though we put the embryos in the uterus, sometimes they can wander into the tube, or more rarely, down into the cervix.  Tubal pregnancies occur in about 2-3% of IVF preg  Tubal adhesions increase the risk of an ectopic.
 Treatment is with medication (Methotrexate) or surgery. For Information and Support . .
 Ask questions during your visits or call us at (212) 263-8990 during regular hours of 9:00AM to 5:00PM.
 Use the written materials and videos available in our library, located off the patient waiting area.  Visit our web site at www.NYUFertilityCenter.org
Injection training videos are available (English and Spanish) through our website – look for this icon on any pageexcept the homepage  Ask our staff for the names of additional patient advocacy, education and information programs.
 Wellness Program Services are most effective when started prior to your cycle.
Psychological Support Staff Shelley S. Lee, Ph.D.
Mindy R. Schiffman, Ph.D.
(212) 263-0060 (212) 263-0061 Psychological Support Services  Consultations, treatment/support sessions for couples  Consults are mandatory for all patients using donor gametes  All patients/couples may utilize the services of our psychologists-call for an appointment and fee schedule at 212-263-0054  Patient support groups, including:  Stress Management  Therapies related to the mind-body connection and infertility treatment Acupuncture Services  Services are provided by  Lara Rosenthal, L.Ac.
 Belinda Anderson, Ph.D., L.Ac.
 Sara Frohlich, L. Ac.
 Can safely be used prior to and concurrently with fertility medications and procedures  To schedule an appointment with any of the acupuncturists, please call (212) 807-6769 or email info@lararosenthal.com. Mind/Body Support Group  Services are provided by Helen Adrienne, LCSW, BCD  Offered as a series of individual classes or as a one-day group program  Individual consultations are also available you can control how you navigate it.
 If you would like to register, please contact: Yoga for Fertility  Services provided by Tracy Toon-Spencer  Classes are held onsite and offsite (265 W. 72nd St., 2nd Fl.)  Bring your own mat or one will be provided for you  Gentle practice focuses on deep relaxation, guided visualization and breathing to trigger the relaxation response  Safe to practice at any time during your treatment  (212) 375-1688 or TLToon@aol.com  Restorative Yoga offered by Barrie Raffel  Classes are held offsite (371 Amsterdam Avenue)  Soothing practice designed to elicit deep, conscious relaxation using props and lengthening time in poses to deepen their effects  Kimberly Ross, MS, RD, CDN offers integrative holistic nutritional counseling for fertility patients  165 West End Ave., Suite 1K  Fridays at the NYU Fertility Center  Appointments made through Ms. Ross' office.
Financial Considerations Financial Policy- Egg Thaw  You are responsible for payment of all charges. Payment for the full egg thaw fee is due at the start of medication; other services (e.g., cryopreservation), as indicated per our payment policy. By law, co-insurance, co-pays and de  Payment of co-pays, deductible, coinsurance or any fees due to the doctor or program, can be made by cash, check or credit card (Visa, MasterCard or American Express).
 Participating insurers: Aetna, United Healthcare, Empire Plan (Center of Excellence), Optum Health/URN, Oxford Financial Policy- Egg Thaw  Insurance carriers have specific authorization requirements and these must be met by the patient. Do not start a cycle if you have
not been authorized for the cycle ( including repeats and FETs).
Starting without insurance authorization will result in the patient
being responsible for all charges.
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 Providers such as anesthesiologists, laboratories, geneticists, radiologists, or pharmacy and hospital fees are separate from the cycle fees. Your insurance may or may not cover these fees. Contact the provider directly for information. This is a sample list of sources of additional charges and cannot be considered complete. NYUFC cannot be held responsible for any charges related to your cycle that are billed by an outside provider.
 Egg Thaw Cycle*  Endocrine assays and phlebotomy charges  Follicular ultrasound monitoring  Medical management  Embryo transfer  Semen preparation  Luteal monitoring up to initial pregnancy test *Payment due at medication start for self pay patients/charges. Cycle will be cancelled for nonpayment of any charges including but not limited to co-pays, co-insurance, deductible and non-covered services. Individual insurance plans dictate what is included in a cycle. Authorization must be obtained where required in advance of every cycle start.  Frozen Embryo (FET) Cycle*  Endocrine assays and phlebotomy charges  Follicular ultrasound monitoring  Medical management  Lab culture and fertilization  Luteal monitoring up to pregnancy test Payment due at cycle start for self pay patients/non-covered charges. Cycle will be cancelled for nonpayment of any charges including but not limited to co-pays, co-insurance, deductible and non-covered services. Individual insurance plans dictate what is included in a cycle. Authorization must be obtained where required in advance of every cycle start. Other Cycle-Related Charges  Anesthesia (paid to NYU Anesthesia Associates)  ICSI and PGD/PGS* and/or Assisted Hatching and Extended Blastocyst Culturing  Semen cryopreservation (including 6 months of storage)  Additional storage billed semiannually  Additional storage billed annually on 1st day of anniversary month  Diagnostic semen analysis  Non-covered, excluded or experimental services as determined by your benefit *PGD/PGS fees come from 2 sources: NYUFC for embryo biopsy and Reprogenetics or other genetics lab Other Cycle-Related Charges  Psychological services at NYUFC and Wellness services  Urology services* – Outside physician/surgeon and NYUFC Andrology lab  Fertility and other medications –pharmacy  Surgical facility charges (non-IVF) for male partner  Luteal monitoring and OB ultrasounds (following positive pregnancy test)  All tests performed by outside laboratories: PGD-Reprogenetics, Enzo, Genzyme, Quest, Lab Corp, NYU Genetics *Services payable to NYUFC and outside provider of service

Source: http://nyulangone.org/files/eggthaw_orientation_060513.pdf

journals.tbzmed.ac.ir

Advanced Pharmaceutical Bulletin, 2012, 2(2), 141-147 doi: 10.5681/apb.2012.022 http://apb.tbzmed.ac.ir/ Preparation and Evaluation of Tretinoin Microemulsion Based on Pseudo-Ternary Phase Diagram Eskandar Moghimipour 1,2, Anayatollah Salimi 1,2*, Fatemeh Leis 2 1 Nanotechnology Research Center, Jundishapur University of Medical Sciences, Ahvaz, Iran.

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& about . National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)National Institutes of HealthPublic Health Service • U.S. Department of Health and Human Services For Your Information This publication contains information about medicationsused to treat the health condition discussed in this booklet.When this booklet was printed, we included the most up-to-date (accurate) information available. Occasionally,new information on medication is released.